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Aug 19, 2008

Autonomy

This post is in response to this article that I just read about a Women's Clinic in California refusing to help a lesbian couple get pregnant via artificial insemination because of their sexual orientation.

I find it amazing that this issue even exists, and that it's been going on for so long. I know that I am very single minded about this and, because of that, can't even consider that someone else might view this differently. I mean no disrespect, but it's just that I CAN'T BELIEVE THAT PEOPLE THINK THIS WAY.

Who told these people that, when they got their MDs and started practicing, they would be allowed to decide who bears children and who doesn't? Where did they get the notion that they have that kind of authority? My med school is very conservative, and yet is still full of classes stating that patient autonomy trumps the physician and that the patient has the right to determine his or her own path. It makes me crazy when people try to pull this kind of thing - withholding their knowledge or skills because they feel that their belief system trumps the patient's autonomy. That is Wrong. With a capital W.

Note to future and current health care providers: We are not God, so we should not try to act and judge as such. We went into this to help people and to try to heal people. Neither of these goals are accomplished if we restrict people's decisions or apply our perspective to them. They are people - let them decide. Just about all of the major religions today preach to love others and treat them as we would want to be treated. If people (including doctors) applied THAT system of belief to their daily activities, instead of judgment and discrimination, we would never have ever had this conversation.

4 Readers rock!:

Sarah said...

You go!

The Scrivener said...

Well said!

Along a similar vein, there was a leaked proposal from the Department of Health and Human Services about a month ago seeking to validate that sort of discrimination on religious grounds. It actually went so far as to define birth control as a form of abortion, lending credence to the physicians and pharmacists who refuse to write/fill those prescriptions on religious grounds. After a massive blogstorm, it just disappeared into the mists.

~Ashley said...

so, i am in no way defending that doctor's choices, but, i think that the issue is sticker than the initial gut reaction would imply. doctors do this all the time based on other factors/filters--for example, doctors who won't see patients without insurance, those who choose to practice conceirge medicine (i know the spelling on that is probably wrong) or those who choose a practice based only on which part of town the building is in...and that's not to say that any of those are morally right, but this is even touchier of an issue because it involves reproduction. i think it's very hard to balance personal freedom in practice along with moral convictions versus the duty to provide care which we are trained to and skilled at performing.

also, i think that in our medical training, we're often taught about autonomy in the sense of "i (the doctor) want to do this ________ to you, and you (the patient) can refuse" we really don't delve into the opposite, of "i (the patient) want this _______ done to me and you (the doctor) have to or must do it" the only example of the latter might be somebody who decides to be a full code when the doctors agree, but even then, dr. griffith gives a small talk about how we can refuse anything in that setting that we deem to be "futile care"

The Shrink said...

In the UK patients (both in the free National Health Service and privately) can't direct treatment.

The doctor's professional role is to offer appropriate treatment. A capactitated patient then can choose only from what's offered. Managers refer to the UK system as "managed choice" since it isn't truly free choice.

Indeed, doctors have been successfully sued for doing what patients asked for, consented to, had done then were unhappy about. Why? Because the medical intervention wasn't necessary so the patient should never have had it offered. It was unprofessional to cede to the patient's demands instead of offering what was clinically necessary or indicated.

Thus, doctors always have to make a choice in deciding what's appropriate and what to offer a patient, if we're to behave professionally.

As well as explicitly constraining patient choice through valid professional decision making, the second issue is of responsibility. We're not personally professionally responsible for what people at large do. If a mother is a bad parent and becomes pregnant, her physician isn't going to be sued by the mum or child for this event arising.

But, when the situation is known to us and we've to make a clinical decision, we then do become personally professionally responsible. Therefore what commonly happens out there in the big wide world may not be okay for a doctor to do or allow to happen.
If a doctor accepts it, by definition the doctor is saying, "this is acceptable."
To elect to actively make a choice in saying something is acceptable or unacceptable therefore becomes part of our day to day practice.

Sometimes this means we'll have views which are at variance with the patient's views. And because we are professionals who do what's professional, not tradesmen doing just what we're paid to do, we have to stick to saying we'll do or not do what we think is acceptable since obviously we can't do what's unacceptable.

We do therefore compromise patient autonomy on practically a daily basis. The crunch is that our decision making should not be biased, prejudiced or unjust.